ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: DEFENDANT: SMALL CLAIMS DECLARATION RE: DEFAULT IN PAYMENTS IN MEDIATED AGREEMENTS The undersigned creditor in the above-entitled action declares: That the settlement was agreed to by debtor (name) and creditor (name) Debtor agreed to pay creditor per and on the (specify day) $ CASE NUMBER: on (date) to be paid by installments of $ , beginning on (date): day of each month thereafter until paid in full. . If any payment is missed, the judgment against debtor shall be entered. That $ That the installment due on the amount owed by debtor is $ has been paid on the settlement amount. has not been paid and . THEREFORE, creditor requests that the amount owing become a judgment of the court. Executed on , at , California. I declare under penalty of perjury that the foregoing is true and correct. Judgment Creditor The Court orders that $ for a total of Date: SC-7018 [Rev. Feb. 5, 2014] dismissal is set aside; judgment be entered forthwith against debtor in the amount of $ plus costs in the amount of $ . Judicial Officer SMALL CLAIMS DECLARATION RE: DEFAULT IN PAYMENTS IN MEDIATED AGREEMENTS CCP 116.860 American LegalNet, Inc. www.FormsWorkFlow.com